Health care is emerging as a prime contrast between candidates in the Kentucky gubernatorial race this fall, where Republican incumbent Gov. Matt Bevin and Democratic state Attorney General Andy Beshear are locked in a heated battle.

A number of health policy issues have divided Kentuckians during Bevin’s tenure, including his involvement in a lawsuit led by conservatives to overturn the 2010 health care law. Beshear is part of a coalition of Democratic attorneys general defending the law.

Bevin wants to implement rules requiring many Medicaid recipients to report work hours and tried to limit benefits, while Beshear opposed such requirements. On abortion, Bevin signed a law in April banning the procedure after six weeks of pregnancy, while Beshear supports abortion rights.

“The role of health — whether it’s women’s health, reproductive health, the issue of Medicaid, affordable health care access, protecting preexisting conditions — those are ways in which those two individuals are going to try to differentiate themselves and show that they are the lesser of two evils or the person who is looking out for the best interests and the values of the people of Kentucky,” said Capri Cafaro, an adjunct professorial lecturer at the American University School of Public Affairs.

Earlier this month, the candidates engaged in their first Twitter fight of the 2019 general election, arguing over preexisting conditions. Beshear doubled down on protecting health care coverage of preexisting conditions, also the topic of his first ad during the Democratic primary. Bevin suggested he supports such coverage but also wants insurance to be affordable.

Bevin currently has one of the lowest approval ratings of any sitting governor, but he is also a key ally of President Donald Trump — who carried the state with 62.5 percent of the vote in 2016.

“Gov. Matt Bevin has made it clear that providing quality health care is vital to the Bluegrass State and supports President Trump in his efforts to solve the disastrous ACA mess,” Republican National Committee spokesperson Kevin Knoth told CQ Roll Call, referring to the health care law. “While radical Democrats across the country focus on extreme legislation from stripping away private health care to embracing late-term abortion, Gov. Matt Bevin remains dedicated to fighting for Kentuckians and their health care.”

Health care law

The stark difference between the candidates’ positions on the health law could offer a preview of how that issue might be viewed by voters next year during the 2020 elections.

“The role that health care will play in the Kentucky gubernatorial elections is something that Democrats and Republicans are likely to look at as kind of a test case of what could potentially occur and what the implications are of, for example, the future of the Affordable Care Act overall,” said Cafaro.

Before the 2010 law, insurance companies could charge people more or refuse coverage if an individual had a preexisting condition. Beshear has focused on this point, arguing against changes to the law.

“Health care is a basic human right. When I look around my own kitchen table, I see that three out of the four of us in my family have a preexisting condition. And I know that’s true around kitchen tables in every part of our commonwealth,” Beshear said in a statement to CQ Roll Call.

But Randy Kammerdiener, president of Republican marketing and consulting firm Majority Strategies and a former executive director of the Republican Party of Kentucky, downplayed the likelihood that the outcome of the health law would be a determining factor for voters.

“Bevin’s policies have helped ensure a strong economy in Kentucky. The reality is that more people are working than ever before. Most families rely on health insurance provided by their employer,” he said. “It probably means that more Kentuckians have access to health care than ever before. I think it’s a bit of a stretch for Beshear to really make the race about health care.”

He added: “Kentucky is a red state, and I don’t think Beshear can win if Republicans can successfully tie him to Washington liberals who run his party.”

David Turner, spokesperson for the Democratic Governors Association, countered that Bevin’s actions are likely to hurt his campaign.

“There’s just been a level of ham-handedness and very clear partisan motivations for what he’s trying to do with health care without reason or seemingly concern for the consequences for Kentucky’s families,” said Turner. “That’s part of what you’ll hear about throughout the cycle ... his gross mismanagement of Kentucky’s health care system.”

Medicaid challenges

The candidates have different approaches on how to handle Medicaid — the health program primarily for low-income people, which covers about 1.2 million Kentuckians.

Beshear’s father, former Democratic Gov. Steve Beshear, issued an executive order in 2013 to expand the program to individuals earning up to 138 percent of the federal poverty level. Bevin says the program is too expensive for the state.

Amelia Chassé Alcivar, the communications director for the Republican Governors Association, emphasized that Bevin’s record shows he is “fighting for accountability in the Medicaid program, and partnering with the president to secure resources to combat the opioid crisis.”

“Andy Beshear and the Democrats would take Kentucky backward, pushing liberal policies like tax hikes, job-killing regulations, and government-run health care,” she added.

The state is involved in litigation defending its plan to implement Medicaid work requirements. This is Kentucky’s second lawsuit on this type of regulation. The state is appealing the most recent decision by the U.S. District Court for the District of Columbia that invalidated them.

Bevin’s vision would implement an 80-hour-a-month work requirement and require monthly premiums of at least $1. Individuals who don't comply would be locked out of coverage for up to six months.

Bevin has also faced scrutiny for cutting dental and vision benefits for the Medicaid expansion population, though that decision was later reversed.

Beshear’s campaign has said he would stop the work requirements process on his first day of office.

Women’s health

Kentucky is also one of a handful of states facing criticism by Democrats and a number of high-profile companies for passing strict abortion bans this year. Kentucky’s new law banning abortion after six weeks of pregnancy was temporarily blocked in court.

The issue galvanizes voters on both sides of the abortion fight, though many Kentucky politicians traditionally have leaned Republican and opposed abortion.

At a rally earlier this year, Bevin called himself the “most pro-life governor in America.”

His signing of the abortion law won him kudos from anti-abortion groups like Susan B. Anthony List, which is active in this race.

Mallory Quigley, vice president of communications for SBA List, said the group “will be going on offense in this state to educate voters on the stark difference between the candidates when it comes to protecting unborn children and their mothers, and we believe life will be the decisive issue at the ballot box.”

On the other side, abortion-rights groups hope to capitalize on renewed energy over threats to abortion access.

“NARAL is proud to support Andy Beshear based on his record of fighting for Kentucky women and families. As Matt Bevin works alongside extreme anti-choice politicians to roll back reproductive freedom, Kentuckians need a governor who will stand up for their fundamental freedoms more than ever,” NARAL Pro-Choice America National Political Director Nicole Brener-Schmitz told CQ Roll Call in a statement.

Cafaro predicted that ads on reproductive health would be targeted, potentially as digital ads. But an ad for Beshear on protecting access to health care or for Bevin on balancing Medicaid access with responsibility to taxpayers could be geared to a broader audience.

“You can make pretty compelling 30-second ads for both of those sides,” she said.